Flipping the “magic switch” for enrollment in the Children’s Health Insurance Program won’t come cheap for states. In Virginia, the cost of shutting off enrollment with the option of opening it back up again could cost upwards of $300,000.

“If you don’t know six or eight weeks in advance what’s going to happen, do you bite bullet, put changes in place only to have that money wasted—money that could have been spent on covering children?” asked Tricia Brooks, a senior fellow at Georgetown University’s Center for Children and Families.

Even after President Donald Trump last week signed a short-term funding patch adding $2.85 billion to CHIP through March 31, children’s hospitals and healthcare advocates continue to wonder if states have to send out more notices to families warning them that they might have to come up with new coverage plans for their CHIP-enrolled kids.

“Six months from now, CHIP may be authorized, Congress will find a way to agree on the money and no one will be happy, and we’ll get through this, but we’ll look back and [analysts] will talk about billions that were wasted as program almost ended,” said Carolyn Engelhard, associate professor of public health policy at the University of Virginia School of Medicine.

UVA runs a teaching hospital that includes a children’s unit.

Engelhard and others have been assessing the administrative burden states will face as lawmakers wrangled over how to pay for CHIP reauthorization.

Fifteen months is how long states would need to ease families out of CHIP and into new plans, said Brooks, who ran New Hampshire’s CHIP program for 15 years. First states have to freeze enrollment so they don’t accept new kids only to kick them off coverage a few months later; then, when already-enrolled kids come up for renewal, they have to figure out a new coverage option and try to keep those with ongoing treatment in a network where they can continue to see their doctors.

“Biting your nails over what could happen in two weeks is absolutely not the way to do it,” Brooks said.

From a purely logistical standpoint, it would have been nearly impossible for states to freeze enrollment seamlessly on the brevity of notice some states were facing. Virginia, Alabama, Colorado, and Utah were facing a potential Jan. 31 closure of their programs. One state that contracts with Deloitte on its information technology systems was told that the company needed six weeks to get the system ready for the termination, Brooks said.

Stakeholders, including providers, are still on alert now that trust in Congress has eroded. No one knows how far the $2.85 billion will go, or whether they will have to continue spending the time and money to work on contingency plans. States that didn’t want to cause unnecessary worry and stress in families—particularly those with very sick kids who need ongoing treatment—before the holidays. On the other hand, they wanted to give as much warning as possible to those who would be impacted.

While one policy expert who has been asked to consult on the matter said CMS officials had begun to talk about a special enrollment period for kids who might lose CHIP, stakeholders were far from sure how a sudden shift of children to a new network would look.

The vast difference in how states operate their programs also comes into play. Some have a fee-for-service model, others use managed care plans. Some run their programs separate from Medicaid, some CHIPs are part of Medicaid.

What is clear, Engelhard said, is that a larger financial burden would fall on families. CHIP caps all cost-sharing, including deductibles and premiums, at 5% of a family’s income. That’s not the case on the exchanges. If a family has to opt for a bronze plan, the high deductibles and premiums could end up as uncompensated care burden on providers.

What is also sure is that kids’ coverage would not be as robust; and, worst of all for the very ill kids, they may have to change doctors.

Engelhard said she expected many sick kids would ultimately be funneled into disproportionate share hospitals. But DSH hospitals face other uncertainty around federal funds: DSH Medicaid payment cuts are due to kick in Jan. 1 because Congress didn’t reinstate the delay that has been periodically authorized since the Affordable Care Act was enacted.

If the worst does happen, Engelhard said, stakeholders would make sure sick kids are covered. Private philanthropic organizations with deep pockets would step in. But that would simply be a band-aid, she said, and not a longterm solution.

After Congress passed its patch, state officials and stakeholders went into the holidays with some respite from contingency plans for the imminent demise of their programs. Yet, Brooks said, they are now thinking through the practical implications of Congress’ potential inability to act.

Given Congress’ inaction CHIP—which expired on Sept. 30—there’s even more there’s even more trepidation among providers about the prospect of GOP lawmakers reviving the so-called Graham-Cassidy legislation. The bill, which was defeated during the Senate’s attempts to repeal the Affordable Care Act, would essentiall turn the federal government’s spending on healthcare into block grants to states. CHIP covers 9 million children while Medicaid alone covers more than 70 million enrollees.

“To push it all onto the states and say good luck is really pretty foolhardy,” Engelhard said. “I think most people are realizing that.”